Practice makes perfect

Meet Sim-Man. He cannot walk, or talk, or do anything regular humans can do. He can, however, fake a myocardial infarction, pretend to vomit or act as if he is dying.

Sim-Man is an instructional mannequin known as a “simulator,” a fairly recent innovation in the field of medical education. Simulation technology has been in use for years, ranging from simple computer software to complex video games of laparoscopic surgery. But none of it is quite as complex as the high-fidelity Sim-Man, who symbolizes the increasingly significant role technology is playing in the practice of medicine and medical education.

Sim-Man arrived at Yale two years ago, ushered in by Leigh Evans, a Yale-New Haven Hospital emergency room doctor and current director of the simulation program. Since then, he has become an integral part of education at the Yale School of Medicine. Yale is currently in the process of planning a larger simulation center to bring all the various simulation activities from different departments in the Yale School of Medicine into concert with each other.

Students make Sim-Man’s acquaintance during the third year, when they begin their clinical rotations after two years of classroom learning. One of those rotations is a required 12-week block of surgical service, two weeks of which are spent in the emergency department.

During that 12-week period, students spend an hour each week working with Sim-Man, whom Evans pre-programs with vital signs, lab test results and other symptoms, all based on details from actual cases, said Karen Jubanyik, also a YNHH ER doctor who works at the simulation center.

Students are told beforehand the general topic for the day’s simulation so that they can prepare, Evans said. When they arrive, they might be faced with a situation as simple as a patient who complains of shortness of breath and knows he has a heart problem, to a problem as complex as a man who has just been in a motor vehicle accident and whose organs are in critical condition, Jubanyik said.

As the students make and carry out their medical decisions as a team, Evans acts as the mannequin’s voice from the control room and changes the dummy’s vital signs to correspond with the action students take.

Six other students and a group of physicians look on from the control room, linked to the simulation room by a telecommunications system and a one-way mirror.

“They must both diagnose and manage a critically ill patient,” said Jubanyik, a debriefer, “but nobody dies.”

High Stress, Low Risk

James Rapp MED ’10, who led his first mannequin simulator session earlier this week, remembers the process being “nerve-wracking.”

A woman in her early 40s lays on the bed in the emergency room.

“Doctor, it hurts … my stomach hurts,” she says.

“Where does it hurt?” one among a group of medical students says, taking charge.

“I don’t know where. It just really hurts,” she repeats, moaning with the pain. “It’s the worst pain of my life.”

“Has it been hurting for long?” the student asks, now flustered.

“No,” the woman says, her voice gutteral. “I woke up with the pain …”

“What did you do when you woke up?”

“I went to the bathroom, number two, and it was loose and watery,” she said. “Thirty minutes later called for an ambulance.”*

“With this history, we knew that her condition would likely require aggressive management and close monitoring,” Rapp said.

So the team quickly took her vitals, started two IV lines, inserted a Foley catheter and hooked her up to an EKG monitor.

Then, armed with a little more information but no conclusive leads, they took a focused history, looking for respiratory and GI conditions, both in her past and in her family history, and a physical exam, concentrating on the abdomen. Since she was a woman of reproductive age, they obtained a gynecologic history to rule out pregnancy. No luck. The patient’s breathing was becoming labored, the pain worsening by the second.

Finally — after many wrong turns — an upright chest X-ray showed free air under the diaphragm, Rapp said, which clued in the team to its final, and correct, diagnosis: a ruptured duodenal ulcer, consistent with her history of alcoholism.

“We’re thrown in there the first week of the surgery rotation with little in terms of preparation,” he said of the mannequin room. “It makes it more challenging and also simulates real-life situations, where you don’t always have all the answers but something needs to be done anyway.”

Debdut Biswas MED ’09 — who worked with the simulator last year — said the unpredictability of the situation can cause some students to “freak out.”

Indeed, Sim-Man can feel fairly real, Rapp said. The hospital room is set up to look like an emergency room — and “it feels like a hundred things are happening at once” — much as an ER setting might feel in real life.

But at the same time, students can afford to mess up.

Richard Belitsky, dean of student education at YSM, acknowledged that working with the mannequins can be stressful, but that this is not necessarily a pitfall.

“We take what would be a real-world medical experience that could be stressful and allow our students to practice in a circumstance where the risk is much lower,” he said.

Jubanyik said the simulation is generally more stressful for students because in an actual hospital, they would not be expected to deal with such serious problems by themselves until they become upper-level residents.

Ben Zabar MED ’10 agreed, adding that many of the mannequin scenarios simulate real-life scenarios medical students would normally never be asked to deal with — a clear benefit of the technique.

“We’d never be doing that with real patients as unsupervised medical students,” he said. “We put medical students in a very advanced situation — but is there a limit to how far we should take them? How far is too far?”

This is a question that Evans’ research lab, at which Zabar works, is investigating. Zabar said it is important to establish that the time the simulation takes away from the classroom — nearly 150 hours over the 12-session period — is worth its value in observable outcomes.

In their study, which will be conducted over the next two years, Evans and her team will randomize residents into two groups, one of which will receive simulation training for administering advanced central venous IV drips. Following this training, both groups of residents will be rated on their execution of the procedure to determine whether the residents who received simulation training performed better than the residents who did not.

The team is also looking into the impact of stress on the effectiveness of the learning experience by comparing learning outcomes in groups working with the mannequin where they were able to “save” the patient versus situations in which the patient “died.”

“The public really needs to be convinced that this actually makes a difference in outcomes and in students’ ability to take care of patients,” Evans said.

A Human Face

Belitsky said simulation should not be used on its own and is no substitute for direct mentoring and communication between faculty doctors and students. Instead, it must be part of a larger educational philosophy of holistic medicine, he said.

Auguste Fortin, director of the longitudinal communication skills program at Yale, which teaches students how to effectively communicate with patients in a therapeutic way, offered a similar warning.

“Because technology has driven medicine so much to the science side, patients face a loss of personhood if the doctor is focused on the issue rather than the person who happens to have the issue,” Fortin said.

Students need to engage with the patient in order to remember that the doctor-patient encounter consists of more than just a technical procedure, Fortin said. Combining the simulation technology with communications skills, he said, helps prevent such depersonalization. The communications component of Sim-Man — including talking to the patient and calling in consults — helps work toward this goal, as does his program and the standardized patients program, run by Frederick Haeseler, associate clinical professor of medicine.

But far before their third years when they meet Sim-Man in the ER — even as early as three weeks into medical school — students try their hands at their first interaction with “patients.”

“A weird thing happened the other night …” Mr. Keith says. He seems worried, even slightly out of breath.

“On the right side of my neck …” Mr. Keith says, touching the area gently with his palm.

“And …” the medical student fumbles for his next question.

“Break,” a physician cuts in. “Let’s talk about what happened there.”

The look of pain on Mr. Keith’s face suddenly dissolves as student and faculty mentor break to discuss what happened.

Mr. Keith isn’t really in pain, nor was he really woken last night from a neck ache. In fact, he isn’t really “Mr. Keith” at all.

He’s Don Wonderlee, a professional actor who plays the character of Mr. Keith, a middle-aged patient who has been in recovery for alcoholism and drugs for 16 years. When he isn’t starring in Punch and Judy puppet shows and community theatre productions, Wonderlee comes down to YSM and acts out scripted interviews with first- and second-year students — as one of 20 actors who participate in the Yale Standardized Patient Program. Wonderlee has played “Mr. Keith” between 40 and 50 times.

Since its inception in 1993, when the program had eight actors, it has grown under the directorship of Haeseler. Over the past few years, he has trained 30 actors and written some 75 scripts.

The program involves medical students in increasingly more challenging scenarios at several points during their four years at YSM, Haeseler said. First- and second-year students hone the art of the patient interview, Fortin said. During these initial interactions, students are presented with uncomplicated scenarios to enable them to focus on their interview skills — usually common complaints such as stomach pains and headaches, he explained.

The characters are constructed to be realistic and have multiple dimensions, Haeseler explained, encouraging “practice interviews not just with pain in the shoulder but the person experiencing the pain.”

Third-year students delve into more sensitive territory, including a workshop on breaking bad news of a serious illness to a patient, he said. In their last year, students get a taste for “difficult” patients, including seductive and overly belligerent patients, Fortin said.

“It’s an earlier stepping stone,” Biswas said of the standardized patient program. “It’s kind of about getting more comfortable in your own skin. There are 50 ways to skin a cat, but you have to find the way that works best for you.”

Each patient-actor plays a different character who comes in repeatedly for different episodes of illnesses over his or her life — much the way it would occur in real life, Haeseler said.

Patient-actors typically interact with groups of three students and a physician, who acts as a facilitator and supervisor. Various standardized patients rotate through the room for about 20 minutes each, while students practice interviewing them in front of their peers, he said. At any point, students or the faculty member can call a “time out” to discuss situations or provide feedback to each other.

Unlike the mannequin-simulation program, the focus with actor-patients is not on mapping physical symptoms on the body or diagnosing a disease. Students regularly perform procedures like rectal, gynecological and pelvic exams on the patient-actors, but the program emphasizes teaching the correct examination technique.

The use of standardized-patients as a teaching tool has caught on to such a wide extent that the United States Medical Licensing Examination — a qualifying exam at the end of students’ four years — added a section requiring test-takers to assess 12 standardized patients in 15 minutes each. In fact, Haeseler said, patient-actor programs have now been adopted at nearly every medical school across the country.

Haeseler said the program has consistently garnered very positive feedback from students. Much like the mannequin-simulation program, interaction with patient-actors provides a unique opportunity for students to practice a skill while being observed and critiqued by experts in that field.

While in some sense, the two programs may teach overlapping skills, their interaction is more complex than simply being complementary, he said.

The two programs have distinctive philosophical goals: The standardized-patient program teaches communication skills that require interaction with real people and cannot be taught even with the most high-tech of mannequins and computer simulations, he said.

Zabar added that the technology is still too new for mannequin scenarios to reproduce some of the more complicated medical situations that would appear in real life.

And conversely, invasive procedures, like sticking a catheter into a patient’s throat — cannot be done on live, healthy actors.

“They’re definitely really distinct in my mind,” Zabar said.

But Haeseler said he anticipates that, going forward, the two forms of simulation teaching may find themselves in tension with each other.

“The newer technology may find itself competing with the older standardized program,” he said. “We need to figure out a way to integrate the older patients standardized teaching techniques and have it interact with newer virtual teaching techniques.”

Simulation center

A central simulation center could be the key to bringing all the simulation activities at Yale into concert, Evans said.

If built, such a center would house both the mannequins and the host of other simulation activities YSM uses to train residents and physicians. For example, students doing their two-week emergency room training practice Advanced Cardiac Life Support using a computer-module simulation under the supervision of a faculty member. Meanwhile, in the surgery department, residents and surgeons use “video-game-like” simulators that help them practice procedures like gallbladder removal and other laparoscopic surgeries, Evans said.

Evans envisioned the Yale simulation center at a time when similar facilities were springing up at leading medical schools across the country. Her first step was to obtain funding for the mannequin — which, depending on the software’s sophistication, can range in price from $40,000 to $200,000.

Yale’s simulation set-up is currently not nearly as large as those at peer institutions, such the University of Connecticut’s, which was federally funded.

But a larger center may be in the cards for Yale, Jubanyik and Evans said.

Jubanyik said Yale is already in the process of committing large amounts of funding to building a simulation center, and has hired architects to look at possible spaces. She said faculty want the center to be close to the hospital so that residents can use it as well, and Evans said officials are currently debating whether to construct a new building or house the center in an already existing space.

In either case, Evans said the medical school hopes to have a larger, more sophisticated simulation center up and built within 18 months.

The new center, Jubanyik hopes, will employ a full-time engineer and a full-time technical staff, as well as multiple simulated patients to emulate the hectic environment of an ER and force doctors to prioritize quickly. It will have space to train not only medical students and residents but also paramedic students, nursing students and attending physicians who hope to brush up on their skills.

“There’s obviously going to be a lot of demand for it,” Jubanyik said. “If you build it, they will come.”